Visit Occurance* Initial Follow-up Visit Date* MM slash DD slash YYYY District Office InformationDistrict Region* Northern Southern District Office*PensacolaJacksonvilleTallahasseeOrlandoPanama CityGainesvilleDistrict Office*TampaWest Palm BeachMargateMiamiFt. MyersFt. PierceAssigned Agent*Donna LandIan ConwayDavid GoldsmithLance KellyTara JacksonRobert LastingerNathan FrankCarrie SmithFrank AnzaloneWillie WilcoxEugene BakerCarmelita Everett-HoganValentino DempsShontory MontgomeryMelissa GayleStasia BrownMarrio ParkerRebecca MitchellJason WattsRaymond GilmoreGamalier MendezRebecca HerrickGregory AlibertiGina ManningMelissa FanninKevin CoxAnthony CroomSean HillSeth SnellgroveJoseph Tussey JrDavid MclainLinda JerniganMichael CrewsErnest WilsonMiguel HerreraAssigned Agent*Del ShiflettJimmy Dykes IiVirginia CollinsDeborah CaplingerFelicia GarnettDexter RobersonWilliam JarvisSamuel FunaroJeffrey PasternakCasey SimonHeather SerranoHarold WilsonCristobal ReyesJames PerroneRobyn KirkKent StantonJames MarraAdam WhisenantBradley FrankRoxie SnellingsJosette GrullonSacha BoykinClariveth Espada-DiazHolly TelloAlberto InfanteSlade HalvakszIsrael PerezRoberto MaqueiraDavid ThomasMichael LoweryArchie MooreEmilio HaroGustavo LunaMark SteeleRafael BorrotoJulio GonzalezSalofi NuaShelia GeraldJohn DavisLori NielsenNicholas PetowskySean FitzpatrickDwayne JohnsonRebecca Prince-SwiftJennifer NashJoshua AyersLuiz DiasBryan NorgardSandra HillardCarolyn FanaleJonathan PowellAdriana SmithAssisting AgentDonna LandIan ConwayDavid GoldsmithLance KellyTara JacksonRobert LastingerNathan FrankCarrie SmithFrank AnzaloneWillie WilcoxEugene BakerCarmelita Everett-HoganValentino DempsShontory MontgomeryMelissa GayleStasia BrownMarrio ParkerRebecca MitchellJason WattsRaymond GilmoreGamalier MendezRebecca HerrickGregory AlibertiGina ManningMelissa FanninKevin CoxAnthony CroomSean HillSeth SnellgroveJoseph Tussey JrDavid MclainLinda JerniganMichael CrewsErnest WilsonMiguel HerreraAssisting AgentDonna LandIan ConwayDavid GoldsmithLance KellyTara JacksonRobert LastingerNathan FrankCarrie SmithFrank AnzaloneWillie WilcoxEugene BakerCarmelita Everett-HoganValentino DempsShontory MontgomeryMelissa GayleStasia BrownMarrio ParkerRebecca MitchellJason WattsRaymond GilmoreGamalier MendezRebecca HerrickGregory AlibertiGina ManningMelissa FanninKevin CoxAnthony CroomSean HillSeth SnellgroveJoseph Tussey JrDavid MclainLinda JerniganMichael CrewsErnest WilsonMiguel HerreraAssisting AgentDonna LandIan ConwayDavid GoldsmithLance KellyTara JacksonRobert LastingerNathan FrankCarrie SmithFrank AnzaloneWillie WilcoxEugene BakerCarmelita Everett-HoganValentino DempsShontory MontgomeryMelissa GayleStasia BrownMarrio ParkerRebecca MitchellJason WattsRaymond GilmoreGamalier MendezRebecca HerrickGregory AlibertiGina ManningMelissa FanninKevin CoxAnthony CroomSean HillSeth SnellgroveJoseph Tussey JrDavid MclainLinda JerniganMichael CrewsErnest WilsonMiguel HerreraAssisting AgentDonna LandIan ConwayDavid GoldsmithLance KellyTara JacksonRobert LastingerNathan FrankCarrie SmithFrank AnzaloneWillie WilcoxEugene BakerCarmelita Everett-HoganValentino DempsShontory MontgomeryMelissa GayleStasia BrownMarrio ParkerRebecca MitchellJason WattsRaymond GilmoreGamalier MendezRebecca HerrickGregory AlibertiGina ManningMelissa FanninKevin CoxAnthony CroomSean HillSeth SnellgroveJoseph Tussey JrDavid MclainLinda JerniganMichael CrewsErnest WilsonMiguel HerreraAssisting AgentDel ShiflettJimmy Dykes IiVirginia CollinsDeborah CaplingerFelicia GarnettDexter RobersonWilliam JarvisSamuel FunaroJeffrey PasternakCasey SimonHeather SerranoHarold WilsonCristobal ReyesJames PerroneRobyn KirkKent StantonJames MarraAdam WhisenantBradley FrankRoxie SnellingsJosette GrullonSacha BoykinClariveth Espada-DiazHolly TelloAlberto InfanteSlade HalvakszIsrael PerezRoberto MaqueiraDavid ThomasMichael LoweryArchie MooreEmilio HaroGustavo LunaMark SteeleRafael BorrotoJulio GonzalezSalofi NuaShelia GeraldJohn DavisLori NielsenNicholas PetowskySean FitzpatrickDwayne JohnsonRebecca Prince-SwiftJennifer NashJoshua AyersLuiz DiasBryan NorgardSandra HillardCarolyn FanaleJonathan PowellAdriana SmithAssisting AgentDel ShiflettJimmy Dykes IiVirginia CollinsDeborah CaplingerFelicia GarnettDexter RobersonWilliam JarvisSamuel FunaroJeffrey PasternakCasey SimonHeather SerranoHarold WilsonCristobal ReyesJames PerroneRobyn KirkKent StantonJames MarraAdam WhisenantBradley FrankRoxie SnellingsJosette GrullonSacha BoykinClariveth Espada-DiazHolly TelloAlberto InfanteSlade HalvakszIsrael PerezRoberto MaqueiraDavid ThomasMichael LoweryArchie MooreEmilio HaroGustavo LunaMark SteeleRafael BorrotoJulio GonzalezSalofi NuaShelia GeraldJohn DavisLori NielsenNicholas PetowskySean FitzpatrickDwayne JohnsonRebecca Prince-SwiftJennifer NashJoshua AyersLuiz DiasBryan NorgardSandra HillardCarolyn FanaleJonathan PowellAdriana SmithAssisting AgentDel ShiflettJimmy Dykes IiVirginia CollinsDeborah CaplingerFelicia GarnettDexter RobersonWilliam JarvisSamuel FunaroJeffrey PasternakCasey SimonHeather SerranoHarold WilsonCristobal ReyesJames PerroneRobyn KirkKent StantonJames MarraAdam WhisenantBradley FrankRoxie SnellingsJosette GrullonSacha BoykinClariveth Espada-DiazHolly TelloAlberto InfanteSlade HalvakszIsrael PerezRoberto MaqueiraDavid ThomasMichael LoweryArchie MooreEmilio HaroGustavo LunaMark SteeleRafael BorrotoJulio GonzalezSalofi NuaShelia GeraldJohn DavisLori NielsenNicholas PetowskySean FitzpatrickDwayne JohnsonRebecca Prince-SwiftJennifer NashJoshua AyersLuiz DiasBryan NorgardSandra HillardCarolyn FanaleJonathan PowellAdriana SmithAssisting AgentDel ShiflettJimmy Dykes IiVirginia CollinsDeborah CaplingerFelicia GarnettDexter RobersonWilliam JarvisSamuel FunaroJeffrey PasternakCasey SimonHeather SerranoHarold WilsonCristobal ReyesJames PerroneRobyn KirkKent StantonJames MarraAdam WhisenantBradley FrankRoxie SnellingsJosette GrullonSacha BoykinClariveth Espada-DiazHolly TelloAlberto InfanteSlade HalvakszIsrael PerezRoberto MaqueiraDavid ThomasMichael LoweryArchie MooreEmilio HaroGustavo LunaMark SteeleRafael BorrotoJulio GonzalezSalofi NuaShelia GeraldJohn DavisLori NielsenNicholas PetowskySean FitzpatrickDwayne JohnsonRebecca Prince-SwiftJennifer NashJoshua AyersLuiz DiasBryan NorgardSandra HillardCarolyn FanaleJonathan PowellAdriana SmithLicensee InformationLicense Number* License Rank DBA County*AlachuaBakerBayBradfordBrevardBrowardCalhounCharlotteCitrusClayCollierColumbiaDeSotoDixieDuvalEscambiaFlaglerFranklinGadsdenGilchristGladesGulfHamiltonHardeeHendryHernandoHighlandsHillsboroughHolmesIndian RiverJacksonJeffersonLafayetteLakeLeeLeonLevyLibertyMadisonManateeMarionMartinMiami-DadeMonroeNassauOkaloosaOkeechobeeOrangeOsceolaPalm BeachPascoPinellasPolkPutnamSt. JohnsSt. LucieSanta RosaSarasotaSeminoleSumterSuwanneeTaylorUnionVolusiaWakullaWaltonWashingtonVisit InformationVisit Start Time* : Hours Minutes 24 Hour FormatVisit End Time* : Hours Minutes 24 Hour FormatPoint of Contact Point of Contact PhoneOperating Status* Open Closed Enter Maximum Occupancy* Yes Unknown or N/A Posted Number of Maximum Occupancy* If you wish to enter multiple occupancy numbers, click the checkbox pertaining to it belowPosted Number of Maximum Occupancy Selection Inside Occupancy Outside Occupancy Other Occupancy Posted Inside Occupancy* Posted Outside Occupancy* Posted Other Occupancy* Enter Occupancy at the Time of Visit* Yes Unknown or N/A Occupancy at the Time of Visit* If you wish to enter multiple occupancy numbers, click the checkbox pertaining to it belowOccupancy at the Time of Visit Selection Inside Occupancy Outside Occupancy Other Occupancy Observed Inside Occupancy* Observed Outside Occupancy* Observed Other Occupancy* In Compliance* Yes No N/A Action Taken* Information Warning N/A Recommendation for Further Action Required?* Yes No Follow-up for Further Action Required?* Yes No Comments
